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702 Effective Accident Investigation
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702 Effective Accident Investigation

Fix the System - Not the Blame

Unfortunately, you might think that the purpose of an employer's investigation aligns with OSHA's mandate. But is this really the case?

Two supervisors outdoors looking at notes
Work together to fix the system.

The issue with assuming that the goal of conducting employer accident investigations is to establish blame lies in the fact that once this goal is achieved, the investigation often stops.

If you think that the main goal of your investigation is to determine fault, then the analysis is deemed complete once blame is assigned. As a result, the investigation ends without further analysis of root causes. This approach also means that the employer fails to meet basic OSHA guidelines for conducting accident investigations.

When the purpose of an investigation is achieved,
IT STOPS!

According to OSHA's Safety and Health Program Management Guidelines, the primary purpose of investigating accidents is to identify their causes and to find ways to prevent future occurrences.

OSHA goes on to say this about the investigation process:

"Although a first look may suggest that 'employee error' is a major factor, it is rarely sufficient to stop there. Even when an employee has disobeyed a required work practice, it is critical to ask, "Why?" A thorough analysis will generally reveal a number of deeper factors, which permitted or even encouraged an employee's action. Such factors may include a supervisor allowing or pressuring the employee to take short cuts in the interest of production, inadequate equipment, or a work practice which is difficult for the employee to carry out safely. An effective analysis will identify actions to address each of the causal factors in an accident or 'near miss' incident."

The Output of Your Investigation

The output of your accident investigation should not merely identify violations of safety rules and assign fault like you would see in an OSHA report. The end product should identify the underlying root causes: the safety management system weaknesses such as inadequate supervision, training, physical resources, or psychosocial support. Effective accident investigation reports do not address the question of fault. Competent managers (safety, human resource, and supervisory) should address the possibility of fault only if the completed accident report cannot identify safety management system weaknesses that contributed to the accident.

Knowledge Check Choose the best answer for the question.

1-8. The end product of an accident investigation should identify the _____.

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